Patient Presentation
An 11-month-old male came to clinic with a 4 hour history of not bending his right elbow. He was playing with his father on a bed and was near the edge. The father pulled the child back toward the center of the bed by the arm. After that the child refused to crawl, but did not cry or appear distressed. After a nap, his parents noted that he refused to eat or take toys with his right hand, but was otherwise well. The pertinent physical exam showed a normal male in no distress sitting on his mother’s lap. His growth parameters were 10-25%. His right elbow was flexed and pronated. He refused to extend and supinate the elbow. There was no palpable abnormalities, tenderness, swelling or bruising from the shoulder to the finger tips. There was normal range of motion in the shoulder, wrist and fingers. The rest of his examination including neurological and skin were normal.
The diagnosis of radial head subluxation was made and because there was no history or physical evidence of probable fracture the decision to treat without a radiograph was made. The elbow was reduced by supination of the forearm and flexion of the elbow. A palpable “pop” was felt over the proximal radius. Within a minute the infant was flexing and supinating the elbow on his own, and repeat examination revealed full range of motion in the elbow. The family was counseled that the child may still not use his elbow normally for a couple of hours but he already seemed to be doing better. The family was also told that this could occur again because of the infant’s age.
Discussion
Radial head subluxation commonly occurs in infants and toddlers because of the anatomy and child development. The radius is connected to the ulna just distal to the radial head by an annular ligament that encircles the radius “neck” (i.e. radial diaphysis) and inserts into the ulnar tuberosity. However the annular ligament is relatively small and also not as fibrous in young children compared to older children and adults. Young children often have their arm extended upward to hold hands with an adult especially when they are new walkers. If the child stumbles or for some other reason has the adult place traction (i.e. pull the extended arm) on the arm, the radial head can be subluxed distally and become entrapped in the ligament. This gives rise to the common name of nursemaid’s elbow. The child may cry in pain or not, but refuses to use the arm, especially the elbow, properly. The adult also may be unaware of what has happened since the incident doesn’t appear to have any trauma associated to it.
Learning Point
There are basically two methods for radial head reduction:
- Elbow supination and flexion
- With the elbow in ~90 degrees of flexion, support the elbow while placing pressure on the radial head.
- Grasp the forearm/wrist and supinate the forearm fully.
- Flex the elbow completely.
- Usually the “pop” of the reduced radial head can be appreciated during elbow flexion.
- Hyperpronation
- With the elbow in ~90 flexion, support the elbow.
- Grasp the forearm/wrist and firmly hyperpronate the elbow.
- Usually the “pop” of the reduced radial head can be appreciated during hyperpronation.
Illustrations and videos of the procedures can be found here.
The hyperpronation technique in some studies has a higher rate of success and may be less painful. One technique may be tried and if it appears unsuccessful the other technique can also be tried. Audible or palpable clicks are often appreciated with proper repositioning, but not always.
In general the shorter amount of time the radial head is subluxed the better, as there is little time for edema to occur. Most children will move the elbow within 30 minutes post reductin. Subluxation that has been present for several to many hours can cause edema, and when the radial head is repositioned, may cause the patient to still have pain and refuse to use the elbow. Children who do not move the arm after an appropriate amount of time may not have the radial head properly repositioned, or the radial head may be entrapped in a partial tear of the annular ligament. Other diagnoses are also possible such as fracture. If a couple of attempts are unsuccessful, then positioning the child in a posterior splint and referral to orthopaedics is indicated.
Radiographs may be considered prior to reduction especially if the history is consistent with greater force (i.e. fell from a height, hit by an object, etc.), history is not consistent with the diagnosis, or there is physical evidence of possible fracture such as swelling, tenderness, bruising or deformity of the elbow or contiguous structures. Positioning the elbow for radiographs may cause a radial head subluxation to be reduced. Therefore a child may return from the radiology suite moving the elbow.
Questions for Further Discussion
1. How often does radial head subluxation recur?
2. What is the treatment for recurrent radial head subluxation?
3. What radiographic findings may indicate an elbow fracture?
Related Cases
- Disease: Radial Head Subluxation | Elbow Injuries and Disorders
- Symptom/Presentation: Extremity Problems
- Age: Infant
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Elbow Injuries and Disorders.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
Macias C, Bothner J, Wiebe R. A Comparison of Supination/Flexion to Hyperpronation in the Reduction of Radial Head Subluxations. Pediatrics. 1998;102:e10.
Kaplan RE, Lillis KA, Recurrent Nursemaid”s Elbow (Annular Ligament Displacement) Treatment Via Telephone. Pediatrics 2002;110;171-174.
Lamb RP. Joint Reduction, Radial Head Subluxation. eMedicine.
Available from the Internet at http://emedicine.medscape.com/article/104158-overview (rev. 11/192009, cited 11/29/2010).
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Pediatric Education 